Tuesday, July 30, 2019

J, Epi & Global Health: Al-Tawfiq & Memish On Hajj Health Concerns

Credit Wikipedia


Jaffar A. Al-Tawfiq and Ziad A. Memish - either writing together or separately - are probably the two best known and most prolific authors on the public health aspects of the Hajj, and since 2012, on the emerging MERS coronavirus.

A partial list of my past blogs highlighting their work include:
AJIC: Intermittent Positive Testing For MERS-CoV
Evaluation of a Visual Triage for the Screening of MERS-CoV Patients
Frontiers Med.: MERS-CoV In 7 Pediatric Patients
ATS: Mass Gatherings And Lessons From The Hajj

The start of this year's the Hajj (Aug 8th-14th) - the largest annual mass gathering of humans on the planet - is now only 10 days away, and so a lot of attention is currently focused on its potential public health impact.

A week ago, in UK PHE Risk Assessment & Travel Advice For MERS-CoV In Saudi Arabia, we looked at the UK's risk assessment, and in May the CDC updated their travelers Advice on the Hajj in Saudi Arabia.

While local threats like MERS-Cov are always a concern - with roughly 2 million pilgrims arriving from all corners of the globe - the most likely threats may lie in less exotic infectious diseases unknowingly brought in by visitors.
The most probable disease outbreak scenarios involve mosquito borne illnesses (like Dengue, Chikungunya, Zika & Yellow Fever), tuberculosis, mumps, measles, chickenpox, norovirus and respiratory viruses like seasonal influenza & Rhinovirus.
In 2015's EID Journal: ARI’s In Travelers Returning From The Middle East, researchers found respiratory infections are the most commonly reported illness among religious pilgrims. This study also found that:
`Pneumonia is the leading cause of hospitalization at Hajj, accounting for approximately 20% of diagnoses on admission.’
Respiratory viruses generally all look alike in their early stages, creating enough `viral noise' to make it difficult to identify and isolate those infected with more serious infections, like MERS (see BMC Inf. Dis.: Clinical Management Of Suspected MERS-CoV Cases).
Today we've an overview of the upcoming Hajj -  along with the recommended and mandatory vaccinations for its visitors - and a look at some of the evolving public health challenges this annual mass gathering presents.
I've only included some excerpts, so follow the link to read it in its entirety.  I'll have a brief postscript when you return.
The Hajj 2019 Vaccine Requirements and Possible New Challenges


Jaffar A. Al-Tawfiq1, 2, 3, *, Ziad A. Memish4, 5, 6
Accepted 5 July 2019, Available Online 25 July 2019.

DOI https://doi.org/10.2991/jegh.k.190705.001How to use a DOI? 


Each year millions of pilgrims perform the annual Hajj from more than 180 countries around the world. This is one of the largest mass gathering events and may result in the occurrence and spread of infectious diseases. As such, there are mandatory vaccinations for the pilgrims such as meningococcal vaccines. 

The 2019 annual Hajj will take place during August 8–13, 2019. Thus, we review the recommended and mandated vaccinations for the 2019 Hajj and Umrah. The mandatory vaccines required to secure the visa include the quadrivalent meningococcal vaccine for all pilgrims, while yellow fever, and poliomyelitis vaccines are required for pilgrims coming from countries endemic or with disease activity. The recommended vaccines are influenza, pneumococcal, in addition to full compliance with basic vaccines for all pilgrims against diphtheria, tetanus, pertussis, polio, measles, and mumps. 

It is imperative to continue surveillance for the spread of antimicrobial resistance and occurrence of all infectious diseases causing outbreaks across the globe in the last year, like Zika virus, MDR-Typhoid, Nipah, Ebola, cholera, chikungunya and Middle East Respiratory Syndrome Coronavirus. 

Copyright© 2019 Atlantis Press International B.V.Open Access
This is an open access article distributed under the CC BY-NC 4.0 license (http://creativecommons.org/licenses/by-nc/4.0/).


Each year millions of people from more than 180 countries gather to perform the annual Hajj pilgrimage in Makkah, Saudi Arabia. The Hajj season occurs at a fixed time each year from 8th to 13th day of the 12th month (Dhu al-Hijjah) in the Islamic calendar [1]. The Islamic/Lunar calendar is 11 days shorter than the Gregorian calendar [1]. 
This year the annual Hajj is expected to take place during August 8–13, 2019. The annual Hajj is one of the largest recurring mass gathering in the world and is the most studied mass gathering [18]. The number of pilgrims traveling to Saudi Arabia is based on the number of Muslims in each country and is calculated as one pilgrim per 1000 Muslims in the specific country [7]. The annual pilgrimage number had increased from 58,584 in 1920 to 3,161,573 in 2012 and of those pilgrims in 2012 about 1,752,932 were international pilgrims coming from outside Saudi Arabia [5]. 

The international pilgrims arrive to Saudi Arabia mainly by air and others may travel via land [4,8,9]. In previous years, there were occurrences of Hajj-related outbreaks [1014] such as the 1987 international meningococcal disease outbreak caused by Neisseria meningitidis serogroup A [1517], and serogroup W135 [18], and the 2000–2001 N. meningitidis outbreak [14,15]. Thus, the annual Hajj requirements are updated annually in response to the occurrence of newly emerging infectious diseases such as Middle East Respiratory Syndrome Coronavirus (MERS-CoV) [1,6,19] and the occurrence of international outbreaks such as Ebola [7,8]. The recommended vaccinations for the Hajj are updated annually [69,20]. 

The 2019 required and recommended vaccinations were issued by the Saudi Ministry of Health [20]. Here, we summarize the 2019 Hajj mandatory and recommended vaccinations and discuss the possible impact of newly occurring outbreaks internationally, one of the most globally spread outbreaks is measles [2123]. 

(Continue . . . )
Six years ago, in MERS, Mass Gatherings & Public Health, we looked at some of the immense challenges that Saudi Arabia faces each year with the Hajj, that go far beyond infectious diseases. Many pilgrims arrive from countries with limited healthcare, are often elderly, and frequently have chronic diseases like diabetes, heart disease, and COPD.
A demographic commonly associated with MERS infection.
While reported MERS activity in Saudi Arabia has thankfully dropped since this year's spring surge, sporadic cases are still begin reported, and some (unknown) number of cases are undoubtedly missed by surveillance.

The good news is, MERS has shown no signs that it is ready or able to embark on a world tour, although three months ago in BMC I.D.: Epidemiological Status Of MERS-CoV - Jan 2017 to Jan 2018 the authors cautioned:
`In today’s “global village”, there is probability of MERS-CoV epidemic at any time and in any place without prior notice.'
So we'll be watching the events during - and the weeks following - the Hajj very closely.